Inspection on 27/04/09 for Ashlyn

This inspection was carried out on 27th April 2009.

CQC found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashlyn 02/05/08

Ashlyn 22/08/06

Ashlyn 03/11/05

Extracts from inspection reports are licensed from CQC, this page was updated on 20/07/2009.

Key inspection report Care homes for older people Name: Address: Ashlyn Ashlyn Vicarage Wood Harlow Essex CM20 3HD     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Jane Greaves     Date: 2 7 0 4 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 37 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 37 Information about the care home Name of care home: Address: Ashlyn Ashlyn Vicarage Wood Harlow Essex CM20 3HD 01279868330 01279868332 julie.cox@excelcareholdings.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Ashlyn Healthcare Ltd Name of registered manager (if applicable) Miss Karin Jung Type of registration: Number of places registered: care home 60 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is 60 The registered person may provide the following categories of service: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Dementia - Code DE Date of last inspection Brief description of the care home Ashlyn is a care home owned by Excelcare Holdings PLC. It is located approximately 2 miles from the centre of Harlow but is within walking distance of shops, and local amenities. Ashlyn is a purpose built home that provides residential accommodation for 60 older people with low to high dependency needs, 31 of whom have Dementia. Care Homes for Older People Page 4 of 37 Over 65 0 60 31 0 Brief description of the care home The home provides personal care to those people who have been assessed as needing this. The home has bedrooms located on both the ground and first floor; the upper floor of the house is accessible to all residents through the passenger shaft lift. The homes bed rates range between £437.50 and £503.58 dependent on assessed needs. Care Homes for Older People Page 5 of 37 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This was an unannounced key site visit undertaken by two inspectors over 8 hours. At this visit we considered how well the home meets the needs of the people living there and how staff and management support people. A tour of the premises was undertaken, care records, staff records, medication records and other documents were assessed. Time was spent talking to, observing and interacting with people living at the home, visitors and staff. Prior to the site visit the manager had completed and sent us the homes Annual Quality Assurance Assessment (AQAA). This is a self assessment document required by law and tells us how the service feels they are meeting the needs of the people living at the home and how they can evidence this. Care Homes for Older People Page 6 of 37 Before the site visit a selection of surveys with addressed return labels had been sent to the home for distribution to residents, relatives and staff. Views expressed by visitors to the home during the site visit and in surveys responses have been incorporated into this report. Feedback on findings was provided to the manager throughout the inspection and the opportunity for discussion and clarification was given. We would like to thank the residents, the manager, the staff team and visitors for the help and co-operation throughout this inspection process. The previous key inspection of this service took place on 1st May 2008. Care Homes for Older People Page 7 of 37 What the care home does well: What has improved since the last inspection? What they could do better: Management and staff demonstrated awareness of the need to promote peoples dignity however daily practice needs to be reviewed to ensure this happens. More should done to promote an enabling environment for the people who live at Ashlyn, especially those people living with dementia. The walls and doors throughout the home are all pale colours, with no distinguishable features, which can be confusing for people with dementia. Good signage would help people identify key areas, such as bathrooms and toilets. Distinguishing features, for example, different coloured doors, doorknockers, pictures and photographs would help people identify their personal rooms. Attention needs be given to cleaning products, both when they are in use and when they are stored away. People may be at risk of accessing these products which would be harmful to their health. Since the previous visit to this service the staff team have been provided with more training to give them the skills necessary to look after people safely and meet their needs. This needs to be continued so that all staff are skilled and knowledgeable about the needs of the people they support. This specifically refers to the completion of the training programme for dementia and challenging behaviours. Daily records did not consistently provide information to reflect how peoples support was provided or how they spent their day. Entries such as all care given does not describe the well being of the individual. Good daily records should incorporate what Care Homes for Older People Page 8 of 37 has worked for the individual that day, where there has been progress, achievements or any concerns about their health and welfare. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 37 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 37 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People moving into Ashlyn can be assured their health needs should be met through a comprehensive assessment. Evidence: Before people moved into the home they were provided with detailed information, enabling them to make an informed decision about whether the home will meet their needs. The Statement of Purpose clearly set out the objectives and philosophy of care, detailing the specialist services provided, quality of the accommodation, qualifications and experience of the staff and how to make a complaint. The managers AQAA reflected that twenty two people living at Ashlyn had impaired vision and nine had impaired hearing. Consideration should be given to providing information about the home and how to make a complaint in a format suitable for people with a visual and/or other sensory impairments. Care Homes for Older People Page 11 of 37 Evidence: Prospective residents and their families/representatives were invited to view the home and discuss their requirements with the management team. They were also invited to spend time at the home before making a decision if this was the right placement for them. We spoke to family members visiting the home on the day of this visit, all confirmed there had been ample information available and that staff and management had been very professional and helpful during the difficult period of finding a care home for people. Information provided in the managers AQAA and verified at the inspection confirmed that before people move in to the home a detailed assessment was carried out to identify peoplesindividual needs. Care plans of three people living in the home were looked at as part of the inspection process, all three contained the required assessments, which provided an overview of their health, personal and social care needs. Staff files and the training schedule reflected that people working in the home had received training to provide them with the required qualifications, skills and experience to meet the needs of the people living in the home. This was tested through discussion with staff during the inspection who demonstrated a good understanding of peoples individual needs. The home does not provide intermediate care. Care Homes for Older People Page 12 of 37 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Inconsistent daily recording means that people cannot be confident their health and well being are being looked after. Daily practice does not protect peoples privacy or promote their dignity. Evidence: Information provided in the managers AQAA and verified during the inspection confirmed that the staff provided care and support based on detailed care plans and assessments relating to mental and physical health as well as nutrition, risk of falls, skin integrity, pressure area care and moving and handling. Examination of three peoples care plans confirmed these were detailed and contained comprehensive information, covering all aspects of individuals health, personal and social care needs. Care plans were stored in lockable cupboards on each unit, the senior staff held the key. On two occasions on this day the cupboards were checked when the care station was unmanned and they were found to be unlocked. When the cupboards are locked the care staff do not have access to the care plans and have to find a senior to get the key. Care Homes for Older People Page 13 of 37 Evidence: Since the previous inspection visit the manager had developed a system for care plan reviews to ensure all peoples care plans were routinely reviewed. The system was called resident of the day where key workers and unit managers know which residents care plans were due for review on what date. The quality of the daily recording varied considerably. One example we looked at was very brief stating all personal care given, whereas another provided good detail to show what support an individual had received with their personal care and how they had spent their day. In discussion some staff members did not demonstrate an understanding about the level of detail necessary to provide an accurate picture of what support had been provided for individuals. The daily records need to be improved to reflect how people have spent their day. For example, good daily records should incorporate what has worked for the individual that day, where there has been progress, achievements or any concerns about their health and welfare. People were supported to access health care services. Dates and details of appointments were recorded in the care plans. Health care needs of the people using the service were managed by visits from the local General Practitioner (GP) and district nurses. Additionally, where required, specialist support was sought from community health services with regards to psychological health and behavioral issues. Records of meetings and reviews reflected that people living in the home and their relatives were invited to participate in the development of care plans. Health professionals involved with the service reported that there had been a noticeable improvement in recent months with things becoming more organised. It was reported that staff were pro-active in accessing advice and guidance and provided good information for health professionals when requested. It was reported, and noted by us during the inspection, that the room allocated for the district nurses for storage was not very hygienic and it was not cleaned often enough. We observed staff still doing the morning medication round at 09:40 hours. Staff told us the round takes a long time due to the large amount of medication individuals were prescribed. Senior carers meeting minutes of 19/02/09 referred to staff concerns that medication rounds were taking a long time. There were five GP surgeries involved in the home. All the local GPs say that annual reviews of peoples medications is their policy. Excelcare say their policy is for 6 monthly reviews. The manager reported constant attempts to arrange reviews for individuals that they felt were receiving excessive medication. One established staff member told us Medications are not reviewed very often, I know that some have never been reviewed and that they were Care Homes for Older People Page 14 of 37 Evidence: concerned about the high amount of medication people were prescribed. Medication was dispensed after the residents lunchtime. This served to ensure that two doses of medication were not administered too close together as a result of the lengthy morning round and staff reported that residents ate a more satisfying lunch if they were not disturbed and distracted by medication being given out at the same time. Senior staff were responsible for the administration of medication. All had received recent pharmacy led training. The manager and deputy assessed individuals competency to safely administer medication by observation at least annually. We looked at the Medication Administration Records (MARs), there was a list of staff signatures included at the front of the folder so it was possible to easily identify who had administered medications. For each resident there was a photograph and a list of any identified allergies. There was evidence to show that the photos were updated at least annually to avoid mistakes with identity. There was a list of all the medications administered at the home, giving the reason that each drug had been prescribed, so that if people refused to take their medication for any reason the staff were able to make the decision whether to contact the GP surgery for further advice or guidance. Where residents refused medications the MAR sheet was completed properly with the reason for non administration on the rear of the chart. There were no gaps in recording noted. Comments from meeting minutes included Some of the residents are finding that the language of some of the staff is difficult to understand. One resident said that when she speaks to the men they do not always answer her. Visitors we spoke with confirmed that communication with some of the staff can be a challenge. One person said Staff are fine, theyre very good, one or two of the staff dont always understand what you say to them but I just search out the ones I know to speak to. During this visit we encountered some difficulties with communicating with some of the staff team and observed one resident becoming quite agitated trying to understand what was being asked of them. One person told us I do have difficulty with some of the staff from other countries. I dont understand what they say. We cant speak to each other, we just have to point for what we want Observation and discussion with staff confirmed they are aware of the need to treat people with respect and dignity when delivering personal care. However, during the Care Homes for Older People Page 15 of 37 Evidence: course of the day we noted some examples where practice did not reflect the homes philosophy to promote peoples dignity. Examples included the following: Personal information about individuals, Staff handover sheets, diary of health care appointments, and clipboards with personal and private information such as fluid charts were available on the care station accessible to anyone passing. One person was seen using the toilet with the door wide open. Staff said the person was fully self caring but preferred not to lock them self in. No strategies were in place to promote the persons dignity. Not all residents bedrooms had name plates, some had scraps of paper with names handwritten on them. This did not indicate that the person inside the room was valued or cared for. Most of the ladies were not wearing stockings or tights and had not received support with personal care such as removing facial hair. Minutes of a team meeting held on 22/04/09 stated Aprons on residents who need them at meal times. Saves the residents clothes need changing there was no reference made to whether people chose to wear aprons at the dining table. In some peoples bedrooms we saw instructions taped to wardrobe doors giving basic instruction about peoples needs. For example dementia, depression, continence needs, what to do if the person should fall, what time they liked to go to bed and how to clean their dentures. This did not serve to promote peoples dignity. Feedback about the service obtained from relatives during the inspection and in confirmed they continue to be generally happy with the care their relative receives. Comments included: They make sure they bring Xs tablets and see that he/she takes them all When X moved into the home there was confusion around the tablets. The staff contacted the GP and now it is all sorted out Very happy, the best thing we ever did was to find this home for X I have peace of mind because I know if X is unwell or had a fall they will phone me Its very good there really, the food is really good Sometimes there is not as much communication as I would like about Xs health care needs, has had a water infection lately and has trouble with hearing now, they dont keep me as up to date as I would like. Care Homes for Older People Page 16 of 37 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improved arrangements for the provision of activities mean people are being offered more opportunity to engage in meaningful and enjoyable activities. Evidence: The managers AQAA told us that the homes activities co-ordinator had joined NAPA (the National Organisation for Providers of Activities for Older People) and now has more insight how to stimulate people living with dementia. NAPA is a registered charity with a keen and active interest in providing high quality activity provision for older people. They provide training, information newsletters and inspiration bulletins of different activities for people to take part in. People responding via surveys told us that the arts, crafts and activities that are organised were of a high standard. Most people confirmed they enjoyed activities however we noted there was nothing arranged for people with specific needs such as visual impairment or arthritis. During our inspection visit people told us: Id like a bit more to do, Ive always been on the go, not one to sit about and Id like to have a cookery class. Care Homes for Older People Page 17 of 37 Evidence: The home had a dedicated activity co-ordinator who worked 42 hours per week. Activities were also arranged over weekends. It was positive to note that there was provision at the weekend however the residents had no input at all on Mondays and reported they felt bored when there was no-one available to arrange stimulation for them. It was reported that one person was supported to go out for walks in the community with a carer once or twice per week to orientate themselves with the locality, daily records confirmed this. A specialist dementia activity programme had been developed including such things as sing along, exercise to music, experience tasting sessions such as marzipan and iced biscuits. There was a sensory trolley for people who were bed bound. This played soothing music and reflected restful images onto the walls and ceiling. There was a vast array of art and crafts items for people to be supported to be creative. Activity records for the month of April showed us that games had taken place, Church services, easter events, and an entertainer had visited the home. There was a notice in the entrance hall to indicate what activities were due to take place and planned for the future. The manager told us the service had been granted the funds to create a sensory garden in the grounds. There were plans for gazebos to shelter residents from the sun, raised flower beds to enable people to get involved in gardening, water features, fragrant planting and a potting shed that will be wheelchair accessible for the residents to use. Staff told us how one person enjoyed listening to audio books as they could no longer read but found it hard with the background noise of the home and other peoples televisions. No strategy had been put in place to solve the problem such as headphones for this person so they could enjoy their books again. After lunch we noted there were fifteen people sat in armchairs lined up around the four walls of the room, there was a period of at least 20 minutes where no staff entered the room to interact with people or to check they were safe and happy. Tables were positioned in front of people when they were sat in their armchairs, the manager said this was not as a bid to restrain people from moving around the home but Care Homes for Older People Page 18 of 37 Evidence: because people want to sit that way. We noted one person who was trying to arise from the chair but was unable to do so. There was snooker on the television in the lounge but not one person in the room was watching it. One person said I wish they wouldnt put the snooker on, its boring. Family members visiting the home on the day told us The activities person is brilliant, really works hard with them, Activities are very good, really smashing and They do quite a bit with the residents, they help people to join in activities. Family members spoken with during this inspection visit said they were always made welcome and were able to visit the home at any time. Comments included: We are always made welcome whenever we visit, we are given the key pad number for the front door so can come and go as we please. We observed the lunchtime meal in the downstairs dining room. A hot trolley was brought through from the kitchen so that peoples meals could be dished up in the dining room. Staff asked each person what they wanted at the point of dishing up. On the day of this visit the choices available were vegetable and cheese slices and chicken and mushroom pie, both were pastry dishes. There were 23 people using this dining room, 11 cheese and vegetable slices were available, this would mean there could possibly be no choice remaining towards the end of the sitting if the cheese and vegetable slices proved to be a popular option. Where people required assistance to eat their meal the staff provided gentle and sensitive support. Notes from a unit meeting of April 2009 instructed staff to Give people a choice and dont assume that they want everything on their plate. We are going to change to tureens on the table so residents can serve themselves. During an initial tour of the home at the start of our visit we noted that kitchen staff were preparing the sandwiches for afternoon tea at 09:30 hours. Staff told us these would be covered and placed in the fridge in readiness for tea at 5pm. There was a choice of ham and tomato or tuna and cucumber. There was also a hot option of Toad in the hole. Later in the day we looked in the fridges. The plate of sandwiches for tea was not labeled or dated, the cake was labeled but not dated, and a further smaller plate of sandwiches was not labeled. This is not good practice, if food is not appropriately labeled it is not possible to confirm when it was prepared and therefore how fresh it is. Care Homes for Older People Page 19 of 37 Evidence: A recent Environmental Health services visit in March resulted in Ashlyns being awarded a fifth gold star meaning that it has achieved an excellent food hygiene rating. The manager reported there had recently been work done individually with people asking them what they like/dont like to eat. The home operated a system of protected meal times where doctors, district nurses and families were asked not to visit at meal times so as not to distract people from eating. The manager told us that relatives were invited to eat with residents. The manager and staff told us that finger foods and snacks were available if people should want them. A resident told us I have no complaints about the food, there is too much really. Relatives told us Food is quite nice, X has a small appetite and they were quite concerned that x wasnt eating enough so they are now providing supplements. I have suggested something that I know X likes and will eat but they havent tried it yet, Very happy, X wasnt eating when they moved in here, improved so much I am really pleased and X really enjoys the food. Care Homes for Older People Page 20 of 37 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can confident that their complaints and concerns will be dealt with appropriately, but cannot be assured that staff have enough training to deliver a consistent approach when supporting people with behaviours that can be challenging to others. Evidence: There was a complaints process in place which was on display to people in quite large text on a coloured background. Given the varied abilities of people living at Ashlyn, some with visual impairment and many living with dementia, different formats should be considered to maximise peoples awareness. The information on display also needed updating to make our (CQCs) role clear, and advise people that they can take their concerns to the Local Authority who can investigate individual complaints. The Local Authorities contact details should be provided. On surveys people did not refer to the complaints process but said that they would speak to a member of staff or the manager if they had any concerns. When we looked at complaints records we saw that three complaints had been recorded since the previous inspection. Two related to respite care and were dealt with in liaison with Social Services. The manager had responded appropriately on each occasion. Since the previous inspection the management at the home had been proactive in referring many potential safeguarding incidents to the local authority. Most of these related to resident on resident incidents, and were managed at the time by staff at Care Homes for Older People Page 21 of 37 Evidence: the home. Others related to staff attitude. The Local Authority safeguarding team had not provided good support to the home in managing these. While one was being addressed by social services at the time of this visit, a further 14 remain pending. Although the issues raised have been dealt with the manager said that they have not received any communication from the safeguarding team to say they are happy with actions taken and consider the incident closed. The local safeguarding team should take the lead in deciding how each incident should be managed. This lack of communication, joint working and leaving staff at the home to manage incidents without input from the local safeguarding team potentially leaves people at risk. Training records showed that the staff team had received training in safeguarding vulnerable adults. When we spoke to staff they confirmed that they had undertaken training, and had a good awareness of safeguarding. They said that they would report any incidents to a senior or manager. Senior staff said that information and contact details to enable incidents to be managed was available. Records showed that the correct forms to report incidents to the local safeguarding team were in use, however the local Southend, Essex and Thurrock guidelines could not be found. The homes own policies and procedures in relation to safeguarding was forwarded to us after the visit however the manager could not locate them for us on the day. This lack of information potentially means that staff may not manage incidents consistently or appropriately. As seen from the information above people living at Ashlyn sometimes behave in ways that are challenging to staff and potentially hazardous and upsetting for other residents. We saw that some staff had undertaken training in managing challenging behaviour. The manager said that further training dates for other staff were planned. We saw that the homes policies and procedures contained good information on managing behaviours. On the day of the inspection we were granted entry to the home, we were not asked who we were or to identify ourselves in any way. The person that opened the front door to us walked away and went about their business without saying a word to us. We were able to walk around the home unchallenged until we approached a member of staff to introduce ourselves. Residents told us I get worried at night because people wander in and out of my room at night. I ring the call bell and someone comes to take them out again Relatives told us I feel Mum is safe at Ashlyns, I would be confident to raise any concerns I may have with the management and know who I can go to if I am not satisfied, The worry was making me ill, now I can walk away safe in the knowledge Care Homes for Older People Page 22 of 37 Evidence: that x is safe and being looked after and If I had any concerns I would take them up with the manager or one of the unit managers. I have raised some minor issues with the home and they responded appropriately straight away. Care Homes for Older People Page 23 of 37 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. More could be done at Ashlyn to create a more homely and enabling environment for people to live in. Evidence: We undertook a physical tour of the home on arrival. The walls and doors throughout the home were all pale colours, with no distinguishable features, this can be confusing for people with dementia. Good signage would help people identify key areas, such as bathrooms and toilets. Distinguishing features, for example, different coloured doors, doorknockers, pictures and photographs would help people identify their personal rooms. The flooring in the home varied, many of the communal areas were hard ceramic flooring, there were some laminated floors and some remained carpeted. We raised concerns with the manager around the suitability of the ceramic flooring, it was reported that residents found it easier to move about with walking frames and that there had been no increase in injuries due to falls since the flooring had been installed. Some areas of the home, specifically the first floor, were malodorous. Comments from the managers satisfaction surveys from January 2009 included The smell of urine is often apparent on the dementia unit. More needs to be done to eradicate this. Care Homes for Older People Page 24 of 37 Evidence: It was positive to note that some old time pictures of adverts had been hung on the communal corridor wall in the dementia unit as an effort to minimise the institutional feel and provide visual stimulation for the people living there. These were positioned quite high on the walls and, in the main, above the eye-line for the majority of the people on the unit. There were ample bathroom and toilet facilities available for people to use however, in the main, these were stark, institutional and cold in appearance. There was a stark contrast between visitors/staff toilet and the facilities provided for residents use. The staff and visitors facility had pictures, nice flooring and shelving with ornaments whereas the residents areas were cold and un-homely. The managers AQAA stated, in the our plans for improvement section, To make the bathrooms more interesting by adding plants and pictures etc. To redecorate communal areas in a more homely manner. Noticeboards in the communal areas of the home were used for staff notices such as Unison poster and notices relating to training. There was a noticeboard in the staff room that would have been a more appropriate place for these. By the ground floor nurses station there was a cardboard box of daily records and MARs waiting to be archived on floor together with carrier bag of staff personal items including inhalers. This practice posed a risk to the health safety and welfare of the people living at the home. We looked at many bedrooms, they were generally untidy with incontinence pads stacked up, and had the feel that no attention to detail or care had been provided to make the environment pleasant for people. The manager reported that plastic under bed storage boxes had been purchased so that excess pads could be stored however this was not happening. Some bedrooms were malodorous and one room we looked at that was empty and ready for occupation had a bed frame in poor condition, a stained carpet, blutack marks on walls, tired furniture, a smeared mirror and a view from the window onto an overflowing skip and bins. We found the laundry room unmanned and unlocked, this could potentially be hazardous if a resident should gain access. There were two doors to allow for soiled laundry in one door and clean laundry out of the other, however, one door was blocked meaning that the same portal was used for soiled and clean laundry. Whilst we stood in the laundry talking to staff a carer entered, picked a up a pair of net pants that are worn to help keep incontinence pads in place. Further discussion identified that there was a communal supply of net pants for people to wear if any of their own Care Homes for Older People Page 25 of 37 Evidence: could not be located. Residents clothing was not put away tidily, all clothes were bundled in drawers. Staff told us that this was because residents turned the drawers topsy turvy however the manager acknowledged this was not necessarily the case and that it was a matter already under review. Relatives told us: The laundry service is the only area for concern. There has been problems with things going missing, they are clearly labeled. People were very helpful but it can take a long time before things are found. During our initial tour of the home we noted a trolley with cleaning products on board was left in a corridor whilst the cleaner was inside a residents room cleaning their en suite. This posed a risk of people accessing potentially dangerous chemicals especially as this was on the dementia unit. The staff member told us they were from an agency and that they had been instructed when they came to work at Ashlyn that they must not leave the trolleys unattended. Despite pointing out the danger to this person they did not move the trolley. We alerted a senior carer employed at the home and they took control of the issue. On the ground floor there was a metal store cupboard containing cleaning chemicals in an unidentified room. There was a sign on the cupboard stating This cupboard must be kept locked. This cupboard was in fact locked however the key had been left in the lock and the room was unlocked meaning that this was not secure and posed a potential hazard. Relatives told us Quite good cleanliness in the home generally, I keep my relatives room tidy though. My relatives bedroom is quite untidy. The laundry is not good. Trousers are never hung up, the drawers are always messy with everything just thrown in, I tidy them up when I go in. There is often clothing in the drawers that doesnt belong to my relative. X was wearing a dirty jumper when I visited recently. The shirts always look nice though. I think the home is lovely and clean, there are always cleaners on duty when I go in. Its quite clean, we visit often, cleaners are there every day. Care Homes for Older People Page 26 of 37 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive care and support from trained and caring staff however they may not be employed in sufficient numbers to meet peoples needs. Evidence: During the day we saw that staff interacted in a kind and caring way with residents. One person said, The staff here are good. Comments made in the homes Quality Assurance surveys from relatives and friends included: We are very impressed with the attitude and care the staff show X and the other clients. They are kind, gentle, comforting, and still have a sense of humour and patience in what must sometimes be very tiring and slightly irritating and repetitive circumstances. The staff are very good. I have nothing but praise for the staff. and Some staff enjoy their job, some staff only treat it as a job. The management consider the following staffing levels to be appropriate to meet the care needs of people living at Ashlyn at this time. During the morning a senior is in charge of each floor with four care staff. In the afternoon and evening a senior is in charge of each floor with four care staff upstairs and three care staff downstairs. At night two seniors are on duty with three care staff. Each floor has a unit manager who works two days each week as supernumerary in order to ensure staff supervisions and all the necessary administration is completed. The managers hours are also supernumerary. Housekeeping, catering and administrative staff are also employed. Care Homes for Older People Page 27 of 37 Evidence: The manager advised that that the home currently has two care assistant vacancies and a night senior carer vacancy. Agency staff were used at the home but the manager said that they try to use the same people to provide continuity and consistency for residents. A family member told us: If I ask the staff to do anything they do it, they are really good. There doesnt seem to be enough staff on duty, maybe that is why X hasnt had a bath last week. Rotas viewed showed us that stated staffing levels were being maintained. However, agency staff were not always included on the rota, as they should be to provide a complete staffing picture, but identified on a separate list. During the day we saw that there were periods where staff were not readily available to people. The minutes of a recent residents meeting said: It would be nice to have more staff. One resident said sometimes the staff keep them waiting too long when they want to go to the toilet. On surveys many people said that there were insufficient staff available to them. Comments included as follows; When I ask for help at night there is no one there to help. They walk away. and Sometimes not enough staff. When I call no one comes, have to keep calling out. and Staff language problem. Night staff too rough. Please do not put light on when they arrive in the room. Staffing levels were discussed with the manager who felt that they were generally adequate. They did however acknowledge that the system used for assessing peoples dependency levels, and therefore identifying what staffing is required may not be entirely accurate. Management therefore risk people not being supported by sufficient staff. When we looked at rotas we saw that staff frequently worked a twelve hour shift from 08.00 to 20.00. During the site visit it was identified that some staff were not managing to fit in breaks. Working long shifts is not best practice as staff may become tired and not as able to carry out their duties well. This could be particularly so on the dementia care unit where noise and behaviours can create a stressful environment. Information on rotas indicated that out of 43 care, senior care, and bank staff 25 had achieved a National Vocational Qualification in care. The manager said that all remaining staff, apart from one, were working towards this qualification. This shows that the provider is committed to ensuring that people are looked after by well trained staff. The National Minimum Standards advise that at least half of a homes care staff are trained to this level and Ashlyn has achieved this. We looked at the files of three recently recruited staff to see if procedures that safeguard people are maintained. We saw that recruitment was carried out to a good Care Homes for Older People Page 28 of 37 Evidence: standard, with all checks such as Criminal Records Bureau disclosures(CRB), references, proof of identification, and fitness being carried out before the person starts work. The recruitment files had recently been audited, but some minor shortfalls remained. Two files did not have a recent photograph, one had a CRB confirmation but not a copy of the document, and one person had stated previous training on their application form but no copies of certificates were available. The files of two people looked at were overseas staff working as students. A Certificate of Student Status said In total the student named above is allowed to be in the work placement for up to 35 hours per week. Rotas showed that more than these hours were being worked. The manager said that their understanding was that they could work for up to 40 hours each week. The manager undertook to look into this. Files viewed showed that a good initial induction was undertaken using a set format. Those viewed had been fully completed and signed off. Staff then went on to undertake a range of e-learning modules and training courses that the manager said were equivalent to Skills for Care units. Information on training files supported this. Elearning is used extensively at Ashlyn, and should provide staff with a useful grounding. However sometimes a lot of information is covered in a single session. For example one person completed the e-learning module in health and safety in one day. This module covered: Moving and handling, electricity, risk assessments, accidents and ill health, hazardous substances, workplace health safety and welfare, fire prevention, first aid, occupational health, ergonomics, health and safety law, infection control and health and safety in a health care setting. For some of these elements such as moving and handling, fire and health and safety we saw that additional training had also taken place. The manager said, and information on rotas indicated, that new staff worked initially on a supernumerary basis on each shift to gain an awareness of routines and practice, and get to know the residents. A training matrix provided, and staff spoken, with showed us that staff had opportunities to undertake a range of basic training. The home is registered to provide care for people who have dementia. The training matrix showed that some staff have yet to undertake training in this area. Health professionals involved with the service told us in the what they could do better section of the surveys Dementia training, terminal care training, more trained senior staff, better handover between staff, complete documentation files on an individual patient available at home, visit request. Care Homes for Older People Page 29 of 37 Evidence: Staff were not wearing name badges making it difficult for residents and visitors to the home to know who they were talking to. Care Homes for Older People Page 30 of 37 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a home where their best interests are increasingly considered however their health, safety and welfare are not always protected. Evidence: The manager at Ashlyn had worked there since last September. An application for registration had been made. The manager was experienced, and had a background in nursing including geriatric nursing. They also had an NVQ at level four in care. The manager was looking into providers in order to start the Registered Managers Award, which is a recognised qualification for people managing care homes. The manager felt that they had made good progress since being at Ashlyn and was committed to ensuring that standards continued to improve. They also recognised that a lot of work remains to be done. Some areas identified for improvement were in line with shortfalls identified at this inspection such as premises and cleanliness issues. Other areas we identified such as privacy and dignity issues the manager was less aware of. We saw that there were opportunities for people to express their views on the service Care Homes for Older People Page 31 of 37 Evidence: through regular residents, relatives and staff meetings. Strategies were in place to monitor the quality of the service. The manager said that surveys were sent out to people living at the home, or with an interest in the service, on a regular basis by the organisation. We saw that when these were returned they were compiled into a report with responses highlighted pictorially. The report did not identify how many surveys were sent out, only those returned, which was quite a low amount. People who did respond were generally positive about the care and service provided at Ashlyn. We saw that monthly visits were made by a senior person in the organisation as is required by Regulation. These visits included talking with people using the service. Records viewed showed that other systems were in place to monitor quality and good practice compliance. For example the manager undertook spot checks at weekends and nights. Medication and health and safety audits were undertaken to ensure safe working practices. People can be assured that if they wish the home to hold monies for them that this will be done in a way that protects their interests. Monies held at the home were sampled and correct, records were well maintained. The managers AQAA identified that systems and services were monitored and maintained. When we looked at records we saw that the last weekly test was recorded as being undertaken on 15th March. The manager said that it had been done since that time. Other fire records showed that regular drills were undertaken and that a fire risk assessment was in place. This was now due to be reviewed. During the site visit some health and safety concerns were raised. Concerns related to ensuring that the building was properly monitored to make it as safe as possible for people living with dementia, who may wander and be unaware of hazards. We saw that disposable gloves and aprons were not stored safely but available on grab rails, in bathrooms and so on. Potentially hazardous areas such as the laundry and a cleaning store cupboard were not secured when left unattended. In the cleaning cupboard residents would be able to access harmful cleaning products. On the dementia unit a trolley containing cleaning products was left unattended. Although better organised in other areas, on the dementia unit liquid soaps and gels were placed on sinks where residents would be able to take them. When we arrived at the home we were let in by an agency member of staff. They did not query our presence, and let us wander into the building unchallenged. If this occurs peoples safety could be compromised. A recent environmental health visit found that Excellent standards of food hygiene Care Homes for Older People Page 32 of 37 Evidence: were maintained and awarded the home five stars. A brief look at the kitchen showed us there was food in the fridge that was covered but not labeled to identify what it was or the date it was placed there. A training matrix and discussion with staff showed that training in core areas such as moving and handling was kept up to date. The manager said that there was a moving and handling trainer among the staff group. Staff told us Huge improvement in last 6 months, Staff morale was so bad, The way people talk to residents have improved, Training has improved and The manager has made good progress. A visitor told us I havent noticed any changes in the home since the new manager has been there. Care Homes for Older People Page 33 of 37 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 34 of 37 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 10 12 The manager must ensure that all people living at the home area afforded respect and dignity in all aspects of their daily life. This is so that people feel valued and maintain a sense of self worth 31/05/2009 2 18 12 The manager must ensure 31/05/2009 that a secure system of granting entry to visitors is agreed and that all staff working at the home comply with it. This is to protect and promote the safety and welfare of the people living at the home 3 38 13 The manager must ensure that cleaning products are safely handled whilst staff are using them and stored securely in the home. 31/05/2009 Care Homes for Older People Page 35 of 37 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This is so that people are not at risk from accessing harmful cleaning products Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 7 The daily records need to be improved to reflect how the individual has spent their day, rather than entries all care given as stated in care plan, which does not describe the well being of the individual. For example, good daily records should incorporate what has worked for the individual that day, where there has been progress, achievements or any concerns about their health and welfare. The manager needs to ensure that the local Authority guidelines relating to abuse is available for everyone in the home to access at all times. Consideration should be given to improving the environment for people living with dementia in line with current good practice guidelines, for example clear symbols, photographs and use of colour for recognition and orientation etc. More could be done to improve the environment for the people who live at Ashlyns by eradicating malodours and ensuring peoples rooms are kept clean and tidy. The manager needs to continue working on the training programme at the home to ensure all staff have the skills to look after people with dementia and those people with challenging behaviours. 2 18 3 22 4 26 5 30 Care Homes for Older People Page 36 of 37 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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